Provider Demographics
NPI:1750914321
Name:RUSSELL, BRIAN PATRICK (PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PATRICK
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 NEW HAMPSHIRE ST STE 3M
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-3174
Mailing Address - Country:US
Mailing Address - Phone:785-423-4234
Mailing Address - Fax:
Practice Address - Street 1:730 NEW HAMPSHIRE ST STE 3M
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-3174
Practice Address - Country:US
Practice Address - Phone:785-423-4234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006021325103TC0700X
KS1351103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical